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Clinical Guidance

Deactivating Implantable Cardioverter Defibrillators (ICDs)

Summary This document provides guidance on the management of implantable cardioverter defibrillators (ICDs) towards the end of life and after death.

Document Detail

Document Type Clinical Guideline

Document name Deactivating Implantable Cardioverter Defibrillators (ICDs)

Document location GTi Clinical Guidance Database

Version 1.0

Effective from February 2019

Review date January 2022

Owner Dr Jessica Webb, Cardiology Consultant

Author(s) Jessica Webb, Parisha Khan, Jessica Peplow, Carys Barton, Julia deCourcey, Lindsay Ip, Stamatis Kapetanakis, Gerry Carr-White, Shaheen Khan, Mark Squirrell, Julian Bostock, Aldo Rinaldi, Lucy Jarrett Smith, Julian Bostock, Mark O’Neill

Approved by, date

Superseded documents Guidelines for deactivating implantable cardioverter defibrillators (ICDs) in people nearing the end of their life. March 2013 South London Cardiovascular and Stroke network

Related documents

Keywords Implantable Cardioverter Defibrillator, ICD, magnet, reprogramming, end of life, dying, heart failure, palliative care

Relevant external law, regulation, standards

DH (2008) End of life care strategy: promoting high quality care for all adults at the end of their life

Mental Capacity Act 2005

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Contents

Section Details

Section 1

Introduction

1.2 What is an ICD? Section 2 ICD Deactivations 2.1 ICD deactivation – when to discuss it 2.2 ICD deactivation – how to discuss it 2.3 ICD deactivation – gaining consent 2.4 Support for complex decision making 2.5 Psychological support for patients with ICDs Section 3 How to deactivate an ICD 3.1 ICD deactivation: How to do it 3.2 Use of magnets to temporarily deactivate an ICD Section 4 Cardiac Arrest 4.1 What to do if the patient is in cardiac arrest? Section 5 5.1 What should happen after the patient has died? Section 6 Related Documents and references

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Introduction

1.1 Introduction

Deactivation of implantable cardioverter defibrillators (ICDs) towards the end of life is a key component of advance care planning. Failure to discuss ICD deactivation in a timely and sensitive manner is a significant potential cause of harm in this patient group, potentially cause pain to the dying patient and distress to their family and friends. This document provides guidance on the management of implantable cardioverter defibrillators (ICDs) towards the end of life, during cardiorespiratory arrest, and after death. It has been written by doctors, nurses, and physiologists to improve the dialogue with patients about end of life care care, facilitate better end of life experiences for patients and their relatives, and to improve understanding for patients, relatives and healthcare professionals. This guidance applies to patients aged 18 years or older. 1.2 What is an ICD? An ICD is an implantable cardioverter defibrillator that is implanted to prevent symptoms and/or sudden death by treating ventricular tachycardia and ventricular fibrillation. It works by identifying an abnormal rhythm and treating it by either attempting to ‘override’ the speed of the heart in controlled bursts (known as ‘antitachycardia pacing’ or ‘overdrive pacing’) or by delivering an electric shock to the heart to reset or restore normal rhythm. When the device is implanted in a patient, physiologists and doctors will program the device appropriately according to the indication for implant. Algorithms are selected to instruct the device to deliver appropriate therapy based on the type of ventricular rhythm it identifies. An ICD can either inserted as a single lead (right atrial or right ventricular) or dual lead (both right atrial and right ventricular) or as a CRTD – cardiac resynchronization therapy defibrillator (right atrial, right ventricular and left ventricular through the coronary sinus). A CRT is a cardiac resynchronization therapy pacemaker without the defibrillator (often known as CRTP, the P indicating pacing). A CRTD has a defibrillator coil. A newer type of ICD (subcutaneous ICD) has a lead that is placed underneath the skin rather than within the heart.

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Figure 1: Differences between pacemakers, ICD, CRT and implantable loop

recorders ATP antitachycardia pacing, CRTD Cardiac Resynchronization therapy Defibrillator

ICD deactivation 2.1 ICD deactivation – when to discuss it Discussion about ICD deactivation is a core component of Cardiology care and Advance Care Planning (ACP), and should be discussed before ICD insertion takes place. Further discussions relating to ICD deactivation can also occur at any stage of the person’s illness, including during ACP discussions and in relation to discussions about cardiopulmonary resuscitation (CPR). In some situations, particularly if ICD deactivation has not been previously discussed with the patient and/or those important to them, the first discussion about ICD deactivation may need to take place around the time of an acute deterioration in the patient’s clinical condition, by a healthcare team that were not directly involved in the insertion of the device. These discussions should be supplemented with senior support from the relevant cardiology and specialist palliative care services as required – support is available 24 hours a day in the hospital and community setting. Sensitive discussions about personalised end of life care can be initiated by any health care professional at any stage of a person’s illness (see Figure 2). These need to be shared decisions with the person, those important to them, and all relevant healthcare professionals.

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Figure 2: Who and when should ICD deactivation be discussed?

2.2 ICD deactivation – how to discuss it It is important that the decision to deactivate an ICD is communicated effectively between the team, and that everyone understands how deactivation has taken place. Deactivating an ICD is not the same as completing a DNACPR order. Deactivating an ICD does not mean the patient will die instantly, or at a set time. It means that the device will not detect and treat fast ventricular rhythms that may result in cardiac arrest. The patient is dying due to the underlying disease, and withdrawing an ICD is analogous to withdrawing renal replacement therapy or artificial ventilation. It is crucial that the bereavement team and mortuary are aware that the patient has an ICD in place and are aware if it has been deactivated. Examples of phrases may include:

“The pacemaker continues to work as always but we prevent the shock part

that may never have activated before from delivering a shock in an

inappropriate circumstance”

“The part of the device that monitors for rhythm disturbances is no longer

suitable so rather than have it shock you unnecessarily we can ensure the

pacemaker continues working without it”

“There may come a time in the future when the part of the device that

monitors you if you need a shock is no longer required as it will not benefit

you. At that point we may wish to adjust the settings”

“Delivery of shocks near the end of life may be ineffective, painful and

distressing to the patient”

“Turning off the ICD will not cause death or be painful”

“Dying may be less painful if the device is turned off”

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“If the patient’s circumstances change following the deactivation, the patient

or medical team can request re-activation”

“Deactivating an ICD can either be done using a magnet or by

reprogramming the device. We would like to reprogram the device at your

usual hospital and will organise an appointment to have this done over the

next few days”

2.3 ICD deactivation – gaining consent Figure 3 outlines the process for obtaining consent for ICD deactivation. The process is underpinned by the principles contained in the Mental Capacity Act (2005). If a patient lacks capacity to share in decision making, then the decision to deactivate an ICD needs to be made in the patient’s best interests, according to the law in that jurisdiction and involve those with the legal power to make these decisions. We recommend referring to Trust guidance on Mental Capacity and best interest decision making.

Figure 3: Consenting the patient for ICD deactivation NOK Next of Kin

2.4 Support for complex decision making It is accepted that in occasional situations, patients’ health may improve and decisions relating to ICD deactivation may be reversed. It is recommended that such cases are discussed at the most appropriate multidisciplinary team meeting with the relevant health care professionals present.

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2.5 Psychological support for patients with ICDs Talking about turning off the device can be distressing for some patients and those important to them, and may be associated with anxiety. The cardiology team will be able to provide support with discussions as well as sign-posting to ICD support group and specialist psychological support. How to deactivate an ICD 3.1 ICD deactivation Local templates should be used for documentation of decisions, ideally stored on the electronic patient record (EPR) that include the patients’ details, reasons for deactivating the device, and the name of the Consultant in charge of the patient’s care who has been involved in these discussions. See Appendix 2 for an example template. An ICD can be deactivated in a planned way (by resetting the device) or can be deactivated in a more urgent situation by placing a magnet over the device. Deactivation requests should be made using the contact details in Appendix 1. In an urgent situation, please contact the relevant Cardiology team and involve the local Palliative Care team.

Figure 4: How to deactivate an ICD

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3.2 Use of magnets to temporarily deactivate an ICD When a magnet is used it is positioned over the device and taped in place (see Figure 5). This can be useful in an emergency situation pending permanent deactivation of the device by trained staff. A magnet temporarily stops the ICD delivering shock therapies whilst in position over the ICD. Normal function is restored as soon as it is removed. Applying a magnet stops shocks occurring if the patient has an arrhythmia. Applying a magnet also does not stop any pacing function of the device, this will continue as normal. Magnets for temporary deactivation of ICDs are held by cardiology departments as well as the community palliative care teams at GSTT and at St Christopher’s Hospice. The magnet is safe for all staff to use. It does not affect staff or relatives who may have active pacemakers. It is safe to touch a patient whilst the ICD is delivering shocks – no shock will be transmitted to the person touching the patient. You will just feel a twitch but try to avoid touching their chest close to the ICD just in case.

Figure 5: Using a magnet to deactivate an ICD

If the skin is damaged, the patient may prefer gauze under the magnet for comfort. Similarly, some patients and relatives may prefer the magnet to be covered. The magnet must remain in place until the physiologist has deactivated the device, even after the patient has died. This means it must remain in place when the patient is transferred to the mortuary. It is possible for the magnet function to be deactivated using the programmer, although in practice this function is rarely used, and if used, should be documented clearly in the patients’ records.

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Cardiac Arrest 4.1 What to do if the patient is in cardiac arrest? There are no special precautions needed when a patient with an ICD has a cardiac arrest. There will be occasions when it is not clear what type of device the patient has in situ. If the patient has a shockable rhythm during an arrest, the ICD is expected to deliver a sequence of shocks to terminate the rhythm. If this is not the case, or the rhythm persists, external defibrillation should be attempted. The pads for external defibrillation should not be placed over or close to the implanted ICD. Interrogation of the device is recommended after a cardiac arrest. After death 5.1 What should happen after the patient has died? If a patient with an ICD has suffered an unexpected sudden death, interrogating the device after death may help to establish the mechanism and cause of death as it may show you the cardiac rhythm and what the device has done beforehand. Once a patient has died the ICD needs to be deactivated by the physiologist before the device is removed or an autopsy is performed. This is to ensure that the person carrying out the procedure is not at risk. All implantable devices must be removed before cremation, as they will explode. Physiology departments have established links with the mortuary to ensure safe disposal of devices after death. After death all ICDs deactivated using a magnet will require subsequent deactivation by a cardiac physiologist using a programmer prior to post mortem, burial or cremation. The deactivated ICD will also need to be removed prior to cremation (normally done by the funeral home / undertaker). Please note that if the patient is in the community the Cardiac Physiologist may not always be able to make visits outside the hospital. There may be a need to arrange for the patient to be bought to local hospital. Early notice will also minimise delays in the funeral arrangements as post mortem and burial cannot be arranged until the ICD has been turned off. If the deceased person is to be cremated, the funeral home will remove the ICD beforehand as standard practice.

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6. Related Documents and references Pitcher D, Soar J, Hogg K, et al. Cardiovascular implanted electronic devices in people towards the end of life, during cardiopulmonary resuscitation and after death: guidance from the Resuscitation Council (UK), British Cardiovascular Society and National Council for Palliative Care Heart 2016; 102: A1–A17. Guidance from the Resuscitation Council (UK), British Cardiovascular Society and National Council for Palliative Care Cardiovascular implanted electronic devices in people towards the end of life, during cardiopulmonary resuscitation and after death March 2015 South London Cardiovascular and Stroke Network, National Council for Palliative Care; Guidelines for deactivating implantable cardioverter defibrillators (ICDs) in people nearing the end of their life. ICD deactivation at the end of life: Principles and practice. A discussion document for healthcare professionals. British Heart Foundation. Carter C. Dying grandfather ‘shocked back to life’ 30 times. http://www.telegraph.co.uk/health/healthnews/10991824/Dying-grandfather-shocked-back-tolife-30-times.html (accessed Dec 2018) Nambisan V, Chao D, Dying and Defibrillation: a shocking experience Palliative Medicine 2004; 18: 482-483 List of Appendices Appendix 1 Contact details of ICD centres to arrange deactivation Appendix 2 Referral request for ICD deactivation – example template

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Appendix 1 Contact details of ICD centres to arrange deactivation All patients should have a card or leaflet with details of their ICD, including the manufacturer and the hospital at which it was implanted. If you call a department, it is useful to have this information to hand. ICD deactivation should ideally be scheduled at the hospital where the ICD was implanted. If the implant details are not known, contact the hospital most conveniently located listed below:

South East London

Guy’s & St Thomas’ Hospital Monday – Friday

9.00am - 5.00pm Pacing/ICD clinic Tel: 0207 401 9249 (diverts to the senior physiologist’s mobile if not answered in 15 seconds) Out of hours: cardiology registrar through switchboard or Coronary Care Unit

King’s College Hospital Monday – Friday

9.00am - 5.00pm Pacing/ICD clinic Tel: 0203 299 8167 / 8165 Email: kch-tr.CRMDevicesKCH@nhs.net Out of hours: cardiology registrar through switchboard or Coronary Care Unit

Queen Elizabeth Hospital Monday – Friday

9.00am - 5.00pm Cardiac department Tel: 0208 836 4343

South West London

St. Georges Hospital Monday – Friday

8.30am - 5.00pm Pacing ICD Clinic Tel: 020 8725 1372/3597 Out of hours: Cardiac Physiologist on call

Croydon University Hospital Monday – Friday

9.00am - 5.00pm Cardiology department Tel: 020 8401 3046 Out of hours: Coronary Care Unit

Epsom Hospital Monday – Friday

9.00am - 5.00pm ECG department Tel: 01372 735735 ext: 6054 Out of hours: Coronary Care Unit

Kingston Hospital Monday – Friday

9.00am - 5.00pm Cardiology Tel: 020 8934 3854 Out of hours: Coronary Care Unit

St Helier Hospital Monday – Friday

8.30am - 5.00pm ECG department Tel: 020 8296 2575 Out of hours: Coronary Care Unit

Should the local centre have a system in place for electronic ICD deactivation requests please following the appropriate protocols.

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Appendix 2 Referral request for ICD deactivation – example template